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Medical History
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Past Medical History
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Past Surgical History
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Comments
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Family History
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Comments
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Mother
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Comments
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Father
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Comments
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Siblings
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Comments
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Social History
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Marital Status
• • •
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Children
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Tobacco use
• • •
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Comments
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Alcohol
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Comments
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Other substances
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Potential Environmental Pathogen
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Comments
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Occupation
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Comments
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